right-sided heart failure related to increased cardiac workload associated with:
pulmonary hypertension (can result from pulmonary vasoconstriction that occurs in response to hypoxia and the release of vasoactive substances)
compensatory response to decreased pulmonary blood flow that results from obstruction of multiple and/or large pulmonary vessels;
extended or recurrent pulmonary embolism related to inadequate response to treatment and/or continued presence of predisposing conditions;
atelectasis related to:
shallow respirations associated with chest pain, fear, and anxiety
stasis of secretions in the alveoli and bronchioles associated with decreased mobility during time that activity is restricted
decreased surfactant production associated with reduced pulmonary blood flow and inadequate deep breathing;
bleeding related to prolonged coagulation time associated with anticoagulant therapy.
The client will not experience extension or recurrence of a pulmonary embolism as evidenced by:
absence of or diminishing chest pain
absence of or decrease in dyspnea
pulse 60 - 100 beats/minute
blood gases returning toward normal.
Nursing Actions and Selected Purposes/Rationales
Assess for and report signs and symptoms of extended or recurrent pulmonary embolism (e.g. development of, persistent, or increased chest pain, dyspnea, apprehension, tachypnea, or tachycardia; declining PaO2).
Administer anticoagulants (e.g. heparin, warfarin) and/or assist with administration of thrombolytic agents (e.g. alteplase [tPA], streptokinase) if ordered to prevent extension of the embolism.
Implement measures to prevent recurrence of a pulmonary embolism:
perform actions to prevent and treat a deep vein thrombus (see Care Plan on Immobility, Diagnosis 12, actions B and C in deep vein thrombosis portion of thromboembolism complication)
perform actions to prevent dislodgment of thrombus:
maintain client on bed rest as ordered
do not exercise, check for Homans' sign in, or massage any extremity known to have a thrombus
caution client to avoid activities that create a Valsalva response (e.g. straining to have a bowel movement, blowing nose forcefully, holding breath while moving up in bed)
prepare client for a vena caval interruption (e.g. insertion of an intracaval filtering device) if planned.
If signs and symptoms of extended or recurrent pulmonary embolism occur:
maintain client on strict bed rest in a semi- to high Fowler's position
maintain oxygen therapy as ordered
prepare client for diagnostic tests (e.g. ventilation-perfusion lung scan, blood gases, pulmonary angiography) if indicated
prepare client for surgical intervention (e.g. embolectomy) if planned
assess for and report signs and symptoms of pulmonary infarction (e.g. hemoptysis, fever, increased WBC count).